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• W15280237 abstract "A twenty-seven-year-old African American female named YP arrives in the emergency department of a large teaching hospital at midnight. She has sickle cell anemia and is in the midst of a sickle cell crisis. She has severe pain in her thighs, arms, hands, and feet. She is dehydrated and anemic. An ED resident instructs a nurse to give her a shot of Demerol for pain and to start a normal saline IV. She is admitted to the hospital. In the hospital, she asks the nurses many questions about the pain medications she is receiving, and she continues to complain about her pain. The following day, two residents, a medical student, and the attending physician visit YP during morning rounds. Neither the physician nor the residents know YP or have seen her before. In the conversation, they discover that she knows a great deal about her disease. When she is not having a crisis, she is able to use a nonsteroidal anti-inflammatory drug, (usually Motrin) to manage her pain. She claims that during a crisis, intravenous morphine provides her with the most effective pain relief, and she asks whether she can be given this drug instead of Demerol (meperidine). She even suggests dosage levels and schedules. In the past, she says that she has used a PCA pump to administer morphine. The pump allows her to have a morphine drip on a round the clock (RTC) basis as well as extra morphine on a prescribe as needed (PRN) basis for breakthrough pain. The medical team is somewhat dumbfounded by YP's request. The attending physician tells YP that they will consider this option, but that they would like to continue treatment with Demerol on a PRN basis. He also asks YP who has treated her in the past so that the team can talk to a physician who knows her well. YP says that she has no primary care physician, but she does name several hospitals where she has received treatment in the past few years. After leaving YP's room, the team discusses her case. One of the residents questions YP's request for a particular kind of pain medication. He is concerned that she may be an addict trying to get a fix and that she likes the euphoria from morphine. Another resident points out that Demorol provides a more euphoric effect than a morphine drip or another opioid, such as methadone. What should they do? commentary Clinicians frequently find management of chronic pain morally and clinically perplexing, despite the availability of effective methods of analgesia and legal and ethical recognition of the patient's right to adequate pain control. While a growing body of literature supports the view that only a small percentage of patients without a previous substance abuse history become addicted to opioids appropriately prescribed for analgesia, many health professionals are concerned about contributing to potential substance abuse problems in patients. This fear of opioids even has a name in the pain literature--opioidophobia. One reason this fear persists is that there is still a small minority of patients who take advantage of the health care system in order to satisfy their addiction needs. Although the proportion of substance abusers is small, these patients can be difficult to manage. Their presence can have a disproportionate effect on the perception and judgment of health care professionals and can create or reinforce a tendency to overestimate the risks of opioid addiction. Thus, it is not surprising that some members of the health care team may want to resist YP's request for specific opioid medications. But recognition of this bias is not an excuse to accede to it. Members of the team should do their best to treat YP fairly: they should form their judgments based on her clinical data and medical and social history, not on their preexisting biases. Thus they should learn more by examining her, talking to her and to her primary care physician (if she has one), and consulting her previous medical records. If all the evidence supports the diagnosis of addiction, the team members might need to treat YP differently from other patients in a sickle cell crisis, but they would still have ethical and legal duties to provide her with adequate pain control. …" @default.
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• W15280237 date "2001-08-02" @default.
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• W15280237 title "Pain and sickle cella anemia." @default.
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